Journal of Deaf Studies and Deaf Education, 2020, 334–350

doi: 10.1093/deafed/enz050
Advance Access Publication Date: 13 February 2020
Empirical Manuscript

EMPIRICAL MANUSCRIPT

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Language and Reading Progress of Young Deaf and
Hard-of-Hearing Children
Shirin D. Antia1,*, Amy R. Lederberg2 , Susan Easterbrooks2 , Brenda Schick3 ,
Lee Branum-Martin2 , Carol M. Connor4 and Mi-Young Webb2
1 Universityof Arizona, 2 Georgia State University, 3 University of Colorado at Boulder, and 4 University of
California at Irvine
*Correspondence should be sent to Shirin D. Antia, University of Arizona, College of Education, Department of Disability and Psychoeducational Studies,
Tucson, AZ 85721, U.S.A. (e-mail: santia@email.arizona.edu)

Abstract
We examined the language and reading progress of 336 young DHH children in kindergarten, first and second grades.
Trained assessors tested children’s language, reading, and spoken and fingerspelled phonological awareness in the fall and
spring of the school year. Children were divided into groups based on their auditory access and classroom communication: a
spoken-only group (n = 101), a sign-only group (n = 131), and a bimodal group (n = 104). Overall, children showed delays in
language and reading compared to norms established for hearing children. For language, vocabulary standard scores were
higher than for English syntax. Although delayed in language, children made expected gains based on hearing norms from
kindergarten to second grade. Reading scores declined from kindergarten to second grade. Spoken-only and bimodal
children had similar word reading and reading comprehension abilities and higher scores than sign-only children.
Spoken-only children had better spoken phonological awareness and nonword reading skills than the other two groups. The
sign-only and bimodal groups made similar and significant gains in ASL syntax and fingerspelling phonological awareness.

Language and literacy development are related areas that
can be adversely affected by childhood hearing loss (Lederberg,
Schick, & Spencer, 2013). Reported language and reading out-
comes of children who are deaf or hard of hearing (DHH) vary
from study to study. Some research suggests that developments
such as newborn hearing screening, early intervention, and the
use of cochlear implants and digital hearing aids have resulted
in DHH children developing age-appropriate language and read-
ing skills in elementary school (Sarant, Harris, & Bennet, 2015;
Tomblin, Oleson, Ambrose, Walker, & Moeller, 2018). Others have
found both language and reading to be delayed (Kyle & Harris,
2011; Tobey et al., 2013). These conflicting findings may be
due to challenges of doing research with a heterogenous low-
incidence population. Some studies include DHH children who
range widely in age, thus obscuring developmental changes.
Others include only a subsection of the population (e.g., children
with cochlear implants (CIs) or those identified early) or only
measure spoken language outcomes.
The present study adds to the literature in two ways. First,
we examine the development of language and literacy skills
as children begin to learn to read. Specifically, we describe
how skills change in comparison to norms across a school year
(longitudinally) and from kindergarten to second grade (cross-
sectionally). Our goal was to determine when and if DHH chil-
dren’s skills differ from hearing children’s during this critical
time period. Second, our large (n = 336) diverse sample allowed
us to compare the development of language and literacy skills
of three groups of DHH children: those who had auditory access
to, and were acquiring spoken language only; those who were
unimodal visual learners and were acquiring sign language; and
those who had auditory access to spoken language and visual
access to sign language and were acquiring both (whom we label

Received March 13, 2019; revisions received November 21, 2019; accepted December 05, 2019

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334

bimodal in this article). Based on theoretical and empirical evi-
dence, we hypothesized that development may differ for these
three groups.
Theoretical Model
The Simple View of Reading (SVR) (Hoover & Gough, 1990;
Tunmer & Chapman, 2012) served as our framework for under-
standing reading development. The SVR posits that reading is
a product of two major components: word identification and
linguistic comprehension. Word identification requires the
(hearing) reader to manipulate the sublexical structure of words
by decoding letters into spoken phonemes and assembling these
into words. Readers can then map the decoded words onto their
knowledge of the semantics and syntax of language to compre-
hend print. The SVR model suggests that the development of
reading, defined as word reading and reading comprehension,
is based on children’s language and phonological awareness
abilities.
Researchers agree that SVR can serve as a framework for
literacy development of DHH children but differ on whether
the model developed for hearing children applies to all DHH
children. The qualitatively similar hypothesis developed by Paul
and colleagues (Paul & Lee, 2010; Trezek et al., 2011) posits that
reading requires knowledge of spoken language and that DHH
children develop reading the same way as hearing children do
but at a slower pace. Other researchers (Hoffmeister & Cald-
well-Harris, 2014; Pettito et al., 2016) believe that DHH children
use alternative visually based skills (i.e., sign language, sign
phonology, fingerspelling) to learn to read. Yet others posit a
third hypothesis—that both views are true, but for different DHH
children depending on their acquisition of spoken and/or signed
language (Lederberg et al., 2013; Miller, 2002).
DHH children differ on their language learning as a function
of their language input and their speech perception abilities
(Lederberg et al., 2013). Those exposed to sign in school and/or at
home acquire sign language because they encounter no sensory
barriers to visual language. On the other hand, speech percep-
tion abilities will determine the acquisition of spoken language.
Because of cochlear implants and digital hearing aids, many, but
not all, DHH children have sufficient speech perception abilities
to acquire spoken language. Children who are not exposed to
sign language will acquire only spoken language. DHH children
who are in signing environments and can perceive spoken lan-
guage may acquire both spoken and signed language and can be
considered bimodal–bilingual.
Based on both reading theory and previous research, we
hypothesized that DHH children’s early reading abilities would
be closely related to phonological awareness and language abili-
ties, but the nature of these skills would be different for these
three groups. We found support for this hypothesis when we
examined the structure of language and literacy skills for these
336 young DHH children using confirmatory factor analyses
(Lederberg et al., 2019). In the group who were only acquiring
sign, reading was strongly related to children’s fingerspelling
phonological abilities and bilingual (ASL and signed English)
language abilities and only moderately related to spoken phono-
logical awareness. In the group who were only acquiring spoken
language, reading was strongly related to spoken phonological
awareness and moderately related to spoken language abili-
ties. For the group of bimodal–bilingual DHH children, reading
was strongly related to both fingerspelling and spoken phono-
logical awareness, as well as their bilingual (ASL and English)
S. D. Antia et al. 335
language abilities. The results supported the hypothesis that
DHH children in these different groups learn to read using
different skills (English, ASL, spoken phonological awareness,
fingerspelling) and underscore the importance of examining
the development of these individual skills. In order to have a
sufficient sample to conduct factor analyses, the previous study
examined language and literacy skills of the kindergarten and
first and second graders as a single group and only used fall
scores in the analysis. The current study extends this research
by examining longitudinal changes in language and literacy
skills from fall to spring, as well as analyzing cross-sectional
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differences between kindergarten, first and second graders. We
describe development and group differences for 13 measures of
language and literacy skills to give a nuanced picture. We also
describe development using normative data to determine how
DHH children’s functioning compares to expectations based on
hearing norms. The following review of research briefly sum-
marizes relatively recent language and literacy outcome studies
of young DHH children between approximately 5 and 9 years
of age with specific attention to those that report change over
time.
Language of Young DHH Children
Much of recently published research focuses on spoken language
outcomes of children with CIs (see Ruben, 2018 for a review).
We divide these studies by language outcome measure, and
report differences, when available, among children who differ by
communication and/or by language.
Global Language
Authors of these studies administered developmental language
assessments that sampled a number of different language
domains such as the Reynell Developmental Language Scales
(Reynell & Gruber, 1990) or administered multiple assessments
and reported composite language scores. Some authors have
reported delays, often along with a wide range of achievement.
Tobey et al. (2013) evaluated the receptive and expressive spoken
language of 160 implanted children for three consecutive years.
At the 4-year (mean CA 6–4 years) and 6-year (mean CA 8–
4 years) post-implant follow-up, the mean composite standard
scores (SS) were 76.4 and 77.6, respectively, with a range from
69.6 to 94.7. Although children were delayed, they made, on
average, expected progress over time, evidenced by the stable
mean standard score. Hay-McCutcheon et al. (2008) followed a
group of 30 children with CIs between ages 1.5 and 10 years and
found that almost all scored a year or more below age norms;
by 9 years of age, the average language age of the sample was
7.9 years.
In contrast, some researchers have reported age-appropriate
development. Sarant et al. (2015) assessed the spoken language
of 44 8-year-old children with CIs and reported a mean SS of
92.5, well within the average range (85–115). Tomblin et al. (2018)
compared the spoken language (and literacy) outcomes of 108
hard-or-hearing (HH) children with a group of hearing controls.
At age 5, the HH children scored significantly lower than the
hearing group, but by age 8 the children with mild and moderate
losses had scores similar to the hearing group. These children
made more progress than expected and “closed the gap” with
their hearing peers. On the other hand, children at both ages
with severe losses scored lower than the hearing group and the
other HH children.
 336 Journal of Deaf Studies and Deaf Education, 2020, Vol. 25, No. 3
Of the studies described, two (Hay-McCutcheon et al., 2008;
Tobey et al., 2013) included participants who used a combi-
nation of spoken and signed communication. Neither group
of researchers reported data separately on children based on
their differences in communication. In their review of research
on language outcomes, Fitzpatrick and colleagues (Fitzpatrick
et al., 2016) concluded that there is, as yet, insufficient evidence
through well-controlled studies to determine whether using a
combination of spoken and signed communication influences
language outcomes of DHH children.
Vocabulary
Several studies report on DHH children’s vocabulary status, but
few have documented growth during the early school years. In
one of the few large studies Connor, Hieber, Alexander Arts,
and Zwolan, (2000) assessed expressive and receptive vocabulary
growth of children with CIs, 66 of whom used spoken and signed
communication, while 81 used spoken language only. At a mean
age of approximately 7 years, the average expressive and recep-
tive vocabulary age was delayed by about 3 years for both groups.
Receptive vocabulary growth was about half that of hearing
norms (0.45 years of growth per year) and did not differ by
communication group. Expressive vocabulary growth (0.70 years
of growth per year) was similar for both groups of children but
with considerable variability among participants. Hayes, Geers,
Treiman, and Moog, (2009) conducted a longitudinal study of
receptive vocabulary growth of 65 children with CIs between 3
and 9 years of age, attending an intensive auditory–oral program.
Children achieved an initial SS of 61 but made greater than
expected annual gains of almost 8 points per year resulting in an
average SS of 81 at 8 years of age. Cupples, Ching, Crowe, Day, and
Seeto, (2013) assessed 101 5-year-old DHH children and reported
an average receptive vocabulary percentile score of 27. They too
reported a large range; some children knew only 4 words while
others knew 112.
Some studies indicate that young children with CIs achieve
vocabulary standard scores within the average range. Geers,
Moog, Biedenstein, Brenner & Hayes, (2009) examined the vocab-
ulary of 153 children 5–7 years of age and reported mean vocab-
ulary standard scores of 91 and 86 for expressive and recep-
tive vocabulary, respectively; between 50 and 58% of children
received standard scores within 1 SD (85–115) of test norms.
Fitzpatrick, Crawford, Ni & Durieux-Smith, (2011) found DHH
4–5-year-olds had an average SS of 91, within the average range,
but significantly below the average SS of 115 achieved by their
hearing peers.
Harris and her colleagues conducted studies that included
children who sign, who only use spoken language and who
use both. Harris, Terlektsi & Kyle, (2017a) found that DHH chil-
dren began school delayed and made only about a third of
the progress of their hearing peers over a 2-year period. Har-
ris, Terlektsi & Kyle (2017b) collected data from a new sample
of children and found that this more recent cohort of DHH
children had higher vocabulary scores than those in their lon-
gitudinal study but still lagged 2 years behind their hearing
peers.
The studies by Connor et al. (2000) and Harris et al. (2017a)
included in their sample DHH children who used spoken lan-
guage and children who signed. Connor et al. reported no differ-
ences between these groups in progress over time, while Harris
et al. found that children who used spoken language had higher
scores than those who used sign. In short, reports on vocabulary
vary by study with several indicating that DHH children score
within the average range and others reporting delays compared
to hearing peers.
Syntax
Children of signing Deaf parents acquire the syntax of sign lan-
guage in a manner similar to that of hearing children acquiring
the syntax of a spoken language (Lillo-Martin & Pichler, 2006).
DHH children of hearing parents typically have parents who are
novice signers, and many primarily acquire sign on school entry.
Enns and colleagues (Allen & Enns, 2013; Enns & Herman, 2011)
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found that preschool and elementary DHH children’s mastery of
ASL structures increased with age and that children with signing
parents (regardless of hearing status) outperformed, at all ages,
those whose parents did not use sign.
For children acquiring spoken language, morpho-syntax
can be difficult to acquire because many essential features
are unstressed and nonsyllabic and therefore difficult to hear.
There is ample documentation of delays in the acquisition of the
syntax of spoken languages by DHH students between the late
preschool and early elementary years. Geers, Nicholas & Sedey,
(2003) found that the DHH children between ages 7–11 and 9–
11 years scored between 2 and 3 standard deviations (SD) below
the norms on tests of receptive English syntax. Geers et al. (2009)
reported that only 33 and 40% of kindergarteners scored within
1 SD of their hearing age-mates in receptive and expressive
English morpho-syntax, respectively. Hay-McCutcheon et al.
(2008) reported that the 30 kindergarten children with CIs in
their study all scored below the 50th percentile on a test of
English morpho-syntax. Duchesne, Sutton & Bergeron, (2009)
examined syntax acquisition of 15 children with CIs between
the ages of 5 and 8 years and reported that 35% scored within
normal limits (i.e., within 1 SD) on comprehension of syntactic
constructions, while 42% scored within 1 SD on comprehension
of morphemes.
Hay-McCutcheon et al. (2008) reported no differences
between children who used spoken and/or sign communication,
but Geers et al. (2003) reported that children who primarily used
spoken communication scored higher on expressive English
syntax than children who used sign. In brief, our knowledge
of ASL syntax acquisition in elementary-aged children is
limited. English syntax acquisition is delayed for many DHH
children including those who have auditory access to spoken
vlanguage.
Reading of Young DHH Children
Historically, median reading scores for DHH students at all grade
levels were reported to be below the norms for hearing students
(Karchmer & Mitchell, 2011) although research with HH children
and those who have CIs shows that many children are achieving
within the average range (see Mayer & Trezek 2018 for a review).
While there are a number of published studies of reading, most
include children within a very wide age range (e.g., Johnson &
Goswami 2010). We briefly review studies of DHH children within
our target age range (5–9 years).
Kyle and Harris (2011) compared the development in word
reading of DHH (CA = 5.8 years) and hearing beginning readers
(CA = 5.0 years), assessing them three times over a 2-year period.
The authors matched the two groups on word reading ability at
the beginning of the study. Eleven DHH children used spoken
language while 13 used sign. Both groups made similar progress
in word reading during the first year; however, the DHH children

made half the progress as the hearing children in the subsequent
year. Harris et al. (2017a) compared the reading progress of a
slightly older cohort of 41 DHH children, ages 6.6 and 8.4 years,
matched on single-word reading with hearing controls. Eighteen
DHH children used spoken language while 26 used sign. Over
a 2-year period, the DHH children made gains of 13 months in
both single-word reading and reading comprehension, while the
hearing children made gains of 31 and 24 months, respectively.
Thus, in both these studies, DHH children lost ground to their
hearing peers as they grew older. In contrast, Tomblin et al.
(2018) found that HH children with mild and moderate hearing
loss made reading progress similar to the hearing control group
between ages 5 and 8 years. However, the children with severe
hearing loss, who had print knowledge similar to hearing peers
at age 5, were significantly behind both the hearing and other
HH children in reading comprehension by age 8.
Some researchers have reported that a considerable per-
centage of children with CIs achieve reading scores within the
average range. Dillon and Pisoni (2006) and Geers (2003) exam-
ined word reading and reading comprehension of DHH chil-
dren with CIs, between 8 and 9 years of age, and included
in their sample children who used spoken language and spo-
ken and signed communication. Dillon and Pisoni reported that
70% of the children received standard scores within 1 standard
deviation (SD) of test norms, while Geers reported that 52%
of children received standard scores within 1 SD of the test
norms.
Phonological Awareness in Young DHH
Children
In order to learn to read, hearing children must be sensitive to
the sublexical structure of words so they can learn to map letters
to spoken phonemes. This requires the development of phono-
logical awareness. Spoken phonological awareness involves the
ability to analyze and manipulate words into their component
sounds. DHH students who have auditory access are able to
develop spoken phonological awareness skills. James et al. (2005)
reported that mean scores of 7- to 10-year-old DHH children
with CIs were higher than chance and showed improvement over
12 months. Most researchers find that DHH children score lower
on these skills when compared to hearing norms and matched
hearing peers. Harris and Beech (1998) examined spoken phono-
logical awareness skills of 44 kindergarten and first grade chil-
dren, of whom 32 used spoken language and 12 used sign.
Although children made progress between fall and spring, their
scores remained, on average, 1 SD below the test norms. Kyle and
Harris (2011), Nittrouer, Caldwell, Lowenstein, Tarr & Holloman,
(2012) and Cupples et al. (2013) all reported that DHH kinder-
gartners scored below comparison groups of hearing children on
spoken phonological awareness tasks. In contrast, James, Rajput,
Brinton & Goswami, (2008) found that children who received CIs
between 2 and 4 years of age achieved phonological awareness
skills similar to hearing peers. Knowledge of spoken phonolog-
ical awareness might also occur through a visual communica-
tion modality. Results of longitudinal studies of French-speaking
children between kindergarten and second grade showed that by
second grade, children who had received consistent and early
exposure to cued speech had phonological awareness scores
similar to a hearing comparison group (Colin, Leybaert, Ecalle
& Magnan, 2013; Colin, Magnan, Ecalle & Leybaert, 2006). Kyle
and Harris (2010) suggest that speechreading, another visual
avenue, can help DHH children acquire the phonological code for
S. D. Antia et al. 337
spoken language. Children who do not have auditory access to
spoken language may develop only limited spoken phonological
awareness skills. Fingerspelling may be an alternative to spoken
phonological awareness for these children because, similar to
spoken phonology, it can be used to manipulate and access
the sublexical structure of printed words. Fingerspelling, which
consists of a manual alphabet representing the English print
alphabet, is a natural part of ASL and many other sign languages.
Fluently fingerspelled words contain some syllable structure
depicted by a sign-like movement or envelope, while chunking
or coarticulation of frequently co-occurring letter sequences
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aids comprehension (Brentari, 1998). Research with signing DHH
adults shows that fingerspelling ability contributes significantly
and independently to reading fluency (Stone, Kartheiser, Hauser,
Pettito & Allen, 2015) and may serve as a means of retaining
print in short-term memory to assist with decoding (Sehyr,
Petrich & Emmorey, 2016). In the present study, we assessed
fingerspelling phonological abilities through imitation of finger-
spelled words, blending fingerspelled letters into fingerspelled
words, and elision, i.e., creating a new word by deleting a finger-
spelled letter(s) from a fingerspelled word. The latter two were
designed to be analogous to spoken phonological awareness
tasks (see Measures). Lederberg et al. (2019) found that finger-
spelling and reading were highly correlated in the current sam-
ple, demonstrating the potential importance of fingerspelling to
reading.
The Present Study
We know surprisingly little about the language and literacy
development of DHH children during elementary school,
especially for those who do not have CIs and are not solely
acquiring spoken language. The present study builds on the
previous findings of Lederberg et al. (2019), in which multi-
group confirmatory factor analyses established across-group
measurement equivalence for the assessments used in this
research project. The factor structure indicated that the
assessments were equally valid indicators of the proposed
underlying constructs of language, reading, and phonological
awareness across the three groups of children (spoken-only,
sign-only, bimodal). This allowed a comparison of the groups’
performance on these three constructs. The language construct
reflected the children’s spoken language abilities for the spoken-
only group but bilingual (ASL and English) abilities for the
bimodal and sign-only groups. The three groups had equivalent
mean language ability or proficiency. Spoken-only and bimodal
children had better reading abilities than sign-only children,
with no differences between the former two groups. Spoken-
only children had better spoken phonological awareness abilities
than bimodal children, who had better abilities than sign-only
children.
While providing an overall picture of DHH children’s
functioning, there were limitations to the previous study. Only
fall raw scores were analyzed, and sample size requirements of
confirmatory factor analyses led us to include kindergarten,
first and second graders as one group. The present study
extends our previous work and examines within-year gains (fall
to spring) as well as differences across grades and language
groups on each of the multiple measures of language and
reading. We have two specific research questions. First, what
is the status (i.e., level of functioning) of young DHH children’s
language and reading compared to the norms for hearing
children? Second, how do language and reading change over
 338 Journal of Deaf Studies and Deaf Education, 2020, Vol. 25, No. 3
a school year and from kindergarten to second grade, and do
status and progress differ by group: spoken-only, sign-only, or
bimodal?
Methods
Participants
Three hundred and thirty-six deaf and hard-of-hearing (DHH)
children participated in this study. Children had to have a
hearing loss (Better Ear-Pure Tone Average, BE-PTA >25 dB);
be enrolled in kindergarten, first or second grade; and be
between the ages of 5 and 9 years to be included. Children
with severe disabilities (defined as the presence of autism and
severe visual or cognitive impairment) were not included. We
included children with mild disabilities (identified as such from
teacher report). We received permission from the University
IRBs and from most schools to notify parents rather than
require individual written consent. We therefore were able
to assess all children who met our eligibility criteria in most
schools.
Children attended 103 different classes in 40 schools
located in nine states in the United States and one Cana-
dian province. A majority of children (87.5%) attended self-
contained classrooms in local elementary programs or in
schools serving only DHH children. The remaining 12.5% of
children attended general education classrooms with hearing
peers.
Groups Children were divided into three groups based on
their auditory access to spoken language and availability of sign
language in the classroom. We determined that children had
auditory access to spoken language if they were able to identify
some referents of spoken words presented through audition
alone on the Early Speech Perception Test (ESP; Moog & Geers, 1990,
see Measures). Signed language was available for those children
whose teachers signed. These two dimensions resulted in the
following three groups:
Spoken-only (n = 101). Children had auditory access to spoken
language and their teachers and parents used only spoken lan-
guage.
Sign-only (n = 131). Children did not have auditory access to
spoken language. Their teachers signed with or without using
spoken language. While these children may have been exposed
to spoken language, they were visual learners because they had
little or no speech perception even with typical amplification
based on their ESP performance.
Bimodal (n = 104). Children had auditory access to spoken
language and teachers signed with or without using spo-
ken language. These children were in the same classrooms
as the sign-only children but differed from them in their
auditory access.
Teachers and examiners (i.e., those who administered study
assessments) completed ratings of children’s language abilities
that indicated our categorization accurately divided the sample.
They confirmed that almost all children in the spoken-only
and sign-only groups used either spoken language or sign. In
the spoken-only group, one child knew some sign language
that teachers rated severely limited. In the sign-only group,
five children knew some spoken language but teachers rated
their abilities as severely limited. Bimodal children varied
in language use, with 74% using both spoken and signed
language, 14% preferring to only use spoken language, and 14%
preferring to only use sign. Teachers of children who signed
(i.e., sign-only and bimodal) reported using ASL only (62%),
using both ASL and signed English (27%), and only signed
English (11%). Thus, the majority of sign-only and bimodal
children were in classrooms where ASL was the language of
instruction.
Table 1 provides the demographic, audiological, and back-
ground characteristics of the three groups of children. Group
differences were examined with chi-square analyses for cat-
egorical data and ANOVAs for interval data. Groups did not
differ in terms of grade, gender, age of diagnosis of hearing loss,
or cognitive abilities. However, they differed in their race/eth-
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nicity. The sign-only group had more White children than the
other groups; spoken-only group had more African–American
children and fewer Hispanic children than the other groups.
The spoken-only group had more children with CIs and better
speech articulation abilities than the other groups. The sign-
only group contained more children with at least one DHH
parent than the other groups. Children in the three grades
did not differ significantly for any background/demographic
measure (see Table S1. Supplemental tables and figures are
online).
Measures
Speech and cognitive measures were used to describe the
children’s abilities. We assessed speech perception with the ESP
(Moog & Geers, 1990). Using an acoustic hoop, examiners asked
children to select referents from a closed set of pictures for
spoken words. Consistent with the test manual, performance
was classified into four categories: 1 = no pattern perception
(0 correct), 2 = pattern perception (discriminated syllabic struc-
ture), 3 = some word identification (selected correct referents
for 33–65% of words), and 4 = consistent word identification
(selected correct referents for more than 65% of words). Children
in the latter two categories were judged to have auditory access
to spoken language. We assessed speech articulation with the Ari-
zona Articulation Proficiency Scale–3 (Fudala, 2000). Children were
asked to supply a spoken word for a series of pictures. Speech
pathology graduate students scored responses from recordings.
Raw scores were converted to degree of speech articulation
impairment based on age norms. We assessed nonverbal IQ with
the DAS-II Matrices subtest (Elliott, 2007). Children were asked
to select a picture that fits a matrix pattern. Raw scores were
converted to T-scores. The normative mean equals 50 with a
SD of 10.
Language We assessed vocabulary with the Expressive One-
Word Picture Vocabulary Test-4 (EOWPVT; Martin & Brownell,
2011) which required children to name pictures of increasingly
unfamiliar items. We accepted both spoken and signed words
(ASL or English). Responses were judged to be correct based
on the manual and a list of acceptable signs developed by
the researchers. We assessed receptive English syntax with the
Elaborated Phrases and Sentences subtest of the Test of Auditory
Comprehension of Language-3 (TACL; Carrow-Woolfolk, 1999).
Children had to select the correct picture after being given a sen-
tence. Assessors administered items in spoken English and/or
in sign. When signing, assessors signed the sentences in English
word order but did not sign English morphemes (e.g., −ed, −s).
They accompanied sign with spoken language based on their
knowledge of children’s preferences. We assessed expressive
spoken English syntax with the Word Structure subtest of the
Clinical Evaluation of Language Fundamentals-4 (CELF; Semel, Wiig
 S. D. Antia et al. 339

Table 1 Demographic characteristics by group

Variable Spoken Bimodal Sign Total

Mean age in years (SD) 6.6 (1.0) 6.6 (0.9) 6.8 (1.0) 6.7 (1.0)
Grade: kindergarten (%) 50 38 34 40
First 28 36 34 33
Second 23 26 31 27
Ethnicity: Hispanic 23 39 30 31
Race: white 44 55 63 55
Black 26 17 11 17
Asian 7 3 8 6

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Other 14 20 8 13
Home language
Spoken English only 69 30 14 36
ASL only 0 9 41 19
ASL + spoken English 3 30 28 21
Spoken language 12 9 7 9
only—not English
Bilingual spoken 15 8 2 8
Deaf or hard-of-hearing 7 23 50 29
parent
Timing of hearing loss
Congenital 52 76 82 65
Acquired 11 4 5 6
Don’t know 35 21 27 28
Audiological technology
Unilateral CI (with or 20 25 14 19
without HA)
Bilateral CI 35 10 7 15
Hearing aid(s) only 45 56 47 51
None 1 3 30 13
Mild additional disability 25 30 19 25
(any)
Attention 8 8 5 7
Cognitive 4 4 2 3
Motor 13 11 6 10
Emotional/behavior 2 5 4 4
Differential ability scale T 46.7(8.1) 46.7 (9.1) 45.9 (8.1)
score M (SD)
Early speech perception
No pattern perception 0 0 93 39
Pattern perception 0 0 7 1
Some word identification 1 1 0 2
Consistent word 99 98 0 58
identification
Level of speech articulation
impairment
None 53 25 — 37
Mild 24 13 — 18
Moderate 21 28 — 25
Severe 2 34 — 20

Note. All numbers are percentages, except where noted otherwise. Percentages may not sum to 100 due to rounding or missing data.

& Secord, 2004). This test uses cloze-set items to elicit expressive
morphology. Examiners administered stimuli to children who
signed using simultaneous communication. Children had to
produce the word with the correct morphology, using either
speech, English signed morphemes, or fingerspelling. We
assessed receptive ASL syntax with the ASL Receptive Skills Test
(Revised) (Schick, 2013). Children watched a recording of a
model signing 32 ASL sentences and selected a picture from
a closed set of three to six pictures for each item. Sentences
assessed complex syntax such as verb agreement, classifiers,
and topicalization.
Reading We assessed reading with three subtests of the
Woodcock–Johnson (WJ) Tests of Achievement III-NU (Woodcock
et al., 2007). We assessed single-word reading with Letter-Word
Identification (WJ Word ID). We required students to identify letters
with spoken or fingerspelled names and single printed words
with spoken and/or signed words. We assessed nonword reading
with Word Attack that requires children initially to express the
sounds of single letters and then to decode nonsense words.
We accepted Visual Phonics and vocal approximations as a way
to represent spoken phonemes. We assessed reading compre-
 340 Journal of Deaf Studies and Deaf Education, 2020, Vol. 25, No. 3
hension with Passage Comprehension (Pass comp) that measure
comprehension of single sentences starting with matching
symbols or rebuses to a picture, followed by matching short
phrases to a picture, and finally, requiring children to provide the
missing word in a sentence. We accepted spoken and/or signed
words.
Phonological awareness (PA) We assessed spoken PA with the
Sound Matching and Blending subtests of Comprehensive Test
of Phonological Processing (CTOPP; Wagner, Torgesen & Rashotte,
1999). Sound Matching required children to select the picture
that matched the initial or final sound of the target picture and
did not require speech. We assumed sign-only children would
use either their knowledge of the spoken phonology of depicted
words or visual (speechreading) information to take this test.
Blending required children to combine spoken sounds to form
spoken words. Assessors administered the directions using each
child’s preferred language and communication, but all items
were delivered in spoken language.
We assessed Fingerspelling PA with three subtests of
the Fingerspelling Ability and Phonological Awareness Test (FS-
PAT; Schick, 2012). Items on the FS-PAT were presented
via a laptop with stimuli signed by a native Deaf signer.
Fingerspelling Imitation (F. Imitation) required children to
imitate a series of fingerspelled real words of increasing
length and difficulty (first item = car, last item = caterpillar).
Fingerspelling Blending (F. Blend) and Elision (F. Elision) sub-
tests were modeled after items on the CTOPP blending and
elision subtests. For F. Blend, children were required to blend
handshapes into a real word; it included eight items of
increasing difficulty (first item = t-oy; last item = g-r-a-ss-h-
o-pp-e-r, with hyphens showing the segmentation). The Deaf
signer paused slightly between the segments and spatially
separated the segments. For F. Elision, the Deaf signer finger-
spelled the word and instructed the child to delete a specific
fingerspelled segment or letter. It included eight items of
increasing difficulty (first item = popcorn without–corn, last
item = strain without–r).
Procedures
Our test battery included tests developed for hearing children.
Standard basal and ceiling rules were used for all tests.
We adapted these tests for use with signing children by having
a team of experts that included native Deaf and hearing signers
meet and establish standard protocols. They then created
recordings of standardized directions, items (e.g., sentences
on the TACL), and a list of acceptable signed responses (all
available from the second author). Examiners were teachers or
speech–language pathologists who were fluent in the children’s
language. The examiners were extensively trained in adminis-
tration procedures and the accommodations based on children’s
language and communication (e.g., identifying acceptable signs
for vocabulary assessments) during a 2-day training workshop.
Examiners who administered the tests to signing children
were provided model recordings of a deaf examiner. Prior to
administering tests to children, they had to administer the tests
to the fourth author, a native signer, for approval.
Examiners administered tests individually in a quiet room.
Children used their typical personal hearing technology. Exam-
iners started testing with the ESP to determine if the child had
access to spoken language. The two assessments that required
spoken language skills (speech articulation, CTOPP blending)
were only given to spoken-only and bimodal children. Initially,
all children received the expressive spoken English syntax (CELF-
WS) test, but testing was discontinued for sign-only children
because they consistently scored at floor. Only those children
who attended classrooms where teachers used sign received the
ASL and fingerspelling assessments.
We maintained scoring integrity in multiple ways. All assess-
ments were recorded. Examiners double-checked their live scor-
ing with these recordings. Graduate students re-scored items for
20% of children randomly chosen (blocked by group). Interrater
agreement ranged from 0.88 to 0.99. Graduate students indepen-
dently calculated standard scores twice and conferenced with
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a third researcher to resolve discrepancies. They independently
entered scores twice into the database, and discrepancies were
resolved by a third researcher. Internal reliability for each test
was calculated for each group for fall and spring. As is evident in
Table S2, reliability values were high (between 0.73 and 0.97) and
similar across groups.
Statistical Analyses
Dependent Variables
For the assessments normed for hearing children, we analyzed
children’s standard scores because effects of time and grade are
more clinically interpretable than raw scores. Stable standard
scores for time or grade would suggest that DHH children were
learning as much as expected based on the norms. An increase in
standard scores would suggest that DHH children were learning
more than expected, while a decrease would indicate that they
were learning less than expected. Because the ASL receptive
syntax and fingerspelling tests did not have normative data, we
used percentage of items answered correctly as the dependent
variable in all analyses for these tests.
Because total raw scores can provide information about
changes in the number of correct test items, indicating that
children are learning the skills measured by the test, we have
graphed total raw scores (number of items correct). For the three
Woodcock–Johnson tests, we graphed W scores which are scaled
total scores that place children on an equal interval metric useful
for measuring growth using a common unit (Woodcock et al.,
2007) (see Figures S1–S4 online).
We calculated the total sample’s average standard score (SS)
and the percentage of children who scored within or above
1 standard deviation (SD) of the normative mean (e.g., 85 or
above; 7 or above). We used this criterion because these standard
scores are considered to be in the average range according to
test manuals. For reference, 85% of hearing children in the
norming samples score within this range. Assessments for
vocabulary, single-word reading, nonword reading, and reading
comprehension had a normative SS mean of 100 and SD of 15.
Assessments for English receptive and expressive syntax and
spoken PA sound matching and blending had a normative SS
mean of 10 and a SD of 3.
For each assessment, using SAS PROC MIXED (SAS Insti-
tute Inc., 2014), we conducted a repeated measure ANOVA with
Time (fall, spring) as the repeated measure and Grade (kinder-
garten, first, second grade) and Group as between-subjects fac-
tors. For vocabulary, English receptive syntax, single-word read-
ing, nonword reading, and reading comprehension, Group had
three levels (spoken-only, bimodal, sign-only). For the English
expressive syntax and spoken PA blending, Group had two levels
(spoken-only and bimodal). For the ASL receptive syntax and
the fingerspelling tests, Group had two levels (bimodal and
sign-only). We adopted α = 0.01 as the criterion for statistical

significance to minimize Type 1 error because all tests were
correlated with each other. Post Hoc tests (Tukey’s HSD) were
conducted when the main effect of Grade or Group was sig-
nificant. Simple effects tests were conducted to examine the
effect of Time for each Grade or Group when there was Time
x Grade or Time x Group interaction. We also calculated the
effect sizes (g; Hedges, 2007) as the model estimated mean
difference adjusted for residual error at fall. Similar to Cohen’s
d, Hedges’ g is the model-based number of standard deviations
that two measures differ (controlling for all other effects in the
model).
Results
The groups scored in the average range for nonverbal IQ with
no group differences. As expected, the groups differed on their
speech abilities (see Table 1). Tables S3–S14 (available online)
present the statistical results of the ANOVAs and follow-up
tests. Because of the volume and complexity of the data,
and to improve readability, we summarize these results in
Table 2. We describe only those effects that were statistically
significant.
Language
Table 3 displays language score means, SDs, and the percentage
of the sample scoring within the average range. Tables S2–S4
display model results.
Vocabulary (EOWPVT)
The total sample had a standard score of 83.2, with 44% of
children scoring within or above 1 SD of the normative mean (i.e.,
above 85). Across the school year, vocabulary standard scores
for the total sample increased from 81.2 to 84.9, g = 0.25. Kinder-
garteners increased their scores from 80.8 to 86.2, g = 0.46. First
graders increased scores from 81.9 to 85, g = 0.19. In second
grade, standard scores were flat. Thus, vocabulary gains across
the school year were greater than the gains which would have
been expected in the normative sample in kindergarten and first
grade and similar to gains expected in the normative sample in
second grade.
Despite the gains occurring during the school year, there
were no significant effects for grade. Children in all three grades
started the school year with standard scores around 80. The
graph of raw scores displayed in Figure S1 (available online)
shows a continuous increase in the number of correct words
with time (i.e., from fall to spring and from grade to grade) and
also shows that growth was similar for the three groups. The only
exception were sign-only kindergarteners who started with low
vocabulary scores but are caught up with the other two groups
by the end of their kindergarten year.
Syntax
English receptive syntax (TACL) The total sample had an average
standard score of 5.8 with 37% of the children within 1 SD of
the normative mean. Scores increased from 5.6 to 6.0 across the
school year, g = 0.17. Children in the spoken-only (mean = 6.2,
g = 0.45) and bimodal (mean = 6.4, g = 0.50) groups scored sim-
ilar to each other but higher than children in the sign-only
(mean = 4.9) group. Figure S1 (online) shows that each group
increased the total correct items with time.
S. D. Antia et al. 341
English expressive syntax (CELF-WS) Spoken-only and bimodal
children had an average standard score of 2.7, more than 2
SD below the normative mean. Only 11% of children scored
within 1 SD of the normative mean. Children in the spoken-
only group showed gains from fall (mean = 2.7) to spring
(mean = 3.5, g = 0.28), but there was no main effect of Group.
Figure S1 shows that children increased the total number of
correct items from fall to spring but both groups scored close
to floor.
ASL receptive syntax Across the school year, scores increased
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from 61.9 to 69.9% correct, g = 0.53. Kindergarteners scored lower
(mean = 56.0%) than first graders (mean = 65.0%, g = 0.60) who
scored lower than second graders (mean = 79.3%, g = 0.90.) As
evident in Table 2 and Figure S1, scores of children in the sign-
only and bimodal groups were very similar and showed steady
improvement from fall to spring and between grades. With an
average of 82.0% correct in the spring, many second graders were
close to ceiling.
Language results summary On vocabulary and receptive and
expressive English syntax, DHH children were delayed com-
pared to test norms. Vocabulary was a strength compared to
children’s knowledge of syntax. English expressive syntax was
severely delayed with almost all children scoring well below the
average range. Overall, children showed improvements on stan-
dard scores from fall to spring, though effect sizes were small,
with the exception of vocabulary learning by kindergarteners
(g = 0.46). Standard scores were similar across grades. Spoken-
only and bimodal children had similar scores on vocabulary and
syntax tests. Sign-only children had similar vocabulary scores
to the other two groups but lower scores on receptive English
syntax (g = 0.45–0.50). On the ASL test, the sign-only and bimodal
children showed remarkably similar and consistent improve-
ment across time and grade.
Reading
Table 4 displays reading standard score means, SDs, and the
percentage of the sample scoring within the average range.
Tables S5–S7 display model results.
Single-Word Reading (WJ Word ID)
The total sample had an average score of 91.2 with 67% of
the children scoring within 1 SD of the norm (at or above
85). Kindergarteners (mean = 95.7) had higher scores than
second graders (mean = 84.9, g = 0.65). Only kindergarteners
significantly increased their scores from fall (mean = 94.5) to
spring (mean = 97.1), g = 0.14. Overall, spoken-only (mean = 96.1,
g = 0.65) and bimodal children (mean = 92.9, g = 0.45) scored
higher than sign-only children (mean = 85.9), with no differ-
ence between the former two groups. Spoken-only children
increased their standard scores from fall (mean = 94.7) to spring
(mean = 97.6, g = 0.15). W scores increased for all three groups
(see Figure S2).
Nonword Reading (WJ Word Attack)
The total sample had an average score of 82.2 with 46%
of children scoring within 1 SD (at or above 85). Standard
scores decreased from fall (mean = 83.5) to spring (mean = 81.0,
g = 0.19). Kindergarteners (mean = 93.2) had higher standard
 342

Table 2 Summary of analysis results: time, grade, and group effects

Construct Test Time Grade Grade ∗ Time Group Group ∗ Time

Language Vocabulary SS F<S (0.25) KF < KS (0.46)

1F < 1S (0.19)
Eng. rec. syn SS F<S (0.17) Spoken > sign (0.45)
Bimodal > sign (0.50)
Eng. exp. syn SS F<S (0.14) Spoken_F < spoken_S (0.28)
ASL rec. syn % F<S (0.53) K<1 (0.60)
1<2 (0.90)
K<2 (1.50)

Reading Single-word SS K>2 (0.65) KF < KS (0.14) Spoken > sign (0.65) Spoken_F < spoken_S (0.15)
Bimodal > sign (0.45)
Nonword SS F>S (0.19) K>1 (0.73) Spoken > bimodal (0.75) Sign_F > sign_S (0.44)
K>2 (1.01) Spoken > sign (1.85)
Bimodal > sign (1.10)
Reading comp. SS F>S (0.19) K>1 (0.90) Spoken > sign (0.59) Sign_F > sign_S (0.33)
1>2 (0.42) Bimodal > sign (0.39) Bimodal_F > bimodal_S (0.21)
Journal of Deaf Studies and Deaf Education, 2020, Vol. 25, No. 3

K>2 (1.32)

Spoken PA Sound match SS Spoken > sign (0.88)

Bimodal > sign (0.60)
Blending SS F<S (0.31) Spoken > bimodal (0.86) Spoken_F < spoken_S (0.53)

Fingerspelling Imitation % F<S (0.58) K<1 (0.79)

1<2 (1.03)
K<2 (1.82)
Blending % F<S (0.50) K<1 (0.60)
1<2 (0.97)
K<2 (1.57)
Elision % F<S (0.56) 1<2 (1.05) 1F < 1S (0.72)
K<2 (1.49) 2F < 2S (0.80)

Note. Effect sizes (Hedges’ g) in parentheses. SS = standard score. % = percent correct. Analyses were from a 2 × 3 × 3 repeated measure ANOVA (fall, spring; grades K-2; sign, spoken, bimodal).

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 S. D. Antia et al. 343

Table 3 Means and standard deviations by time, grade, and group on language measures

Test Score Group Kindergarten First grade Second grade Total % ≥ 85/% ≥ 7

Fall Spring Fall Spring Fall Spring

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

Vocabulary Standard Spoken 82.8 (16.1) 85.5 (16.6) 80.4 (12.5) 82.8 (13.1) 79.5 (10.2) 78.9 (11.2) 82.3 (14.2) 43%
(EOWPVT) score Bimodal 82.1 (13.4) 86.2 (14.8) 83.8 (11.2) 86.5 (15.2) 78.2 (14.6) 81.7 (14.9) 83.5 (14.1) 44%
Sign 76.6 (16.3) 86.9 (16.6) 81.2 (18.2) 86.0 (17.7) 84.0 (11.3) 85.4 (11.3) 83.6 (15.8) 45%
Total 80.8 (15.4) 86.2 (15.9) 81.9 (14.6) 85.3 (15.6) 81.0 (12.2) 82.6 (12.7) 83.2 (14.8)
% ≥ 85 37% 55% 36% 49% 41% 41% 44%

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Eng. rec. Standard Spoken 6.5 (2.9) 6.8 (3.2) 5.5 (2.6) 5.9 (2.6) 5.7 (2.5) 6.7 (2.7) 6.2 (2.9) 40%
syntax (TACL) score Bimodal 6.6 (3.1) 7.0 (3.2) 6.1 (2.6) 5.8 (2.8) 6.0 (2.9) 6.8 (2.4) 6.4 (2.9) 47%
Sign 4.7 (2.9) 4.8 (2.8) 4.4 (2.6) 5.2 (2.7) 5.1 (2.8) 5.7 (2.6) 4.9 (2.7) 28%
Total 5.9 (3.1) 6.2 (3.2) 5.2 (2.7) 5.6 (2.7) 5.5 (2.7) 6.3 (2.6) 5.8 (2.9)
%≥7 43% 44% 34% 34% 29% 37% 37%
Eng. exp. Standard Spoken 3.1 (2.6) 3.9 (3.4) 2.2 (2.1) 3.2 (2.9) 2.6 (2.2) 3.2 (2.4) 3.1 (2.8) 13%
syntax score Bimodal 2.5 (2.9) 2.3 (2.2) 2.1 (2.5) 2.2 (2.6) 2.1 (3.1) 2.3 (3.0) 2.3 (2.7) 9%
(CELF-WS) Total 2.9 (2.7) 3.2 (3.0) 2.1 (2.3) 2.6 (2.7) 2.3 (2.7) 2.7 (2.8) 2.7 (2.7)
%≥7 11% 16% 6% 11% 7% 14% 11%
ASL rec. Percent Bimodal 51.7 (15.3) 60.4 (14.8) 60.3 (14.5) 69.9 (13.5) 73.6 (13.2) 79.5 (9.8) 64.5 (16.5)
syntax (Schick, correct Sign 50.6 (18.5) 61.4 (17.9) 61.0 (18.0) 69.3 (17.8) 78.7 (9.6) 83.9 (9.4) 66.9 (19.3)
2013) Total 51.1 (17.0) 60.9 (16.4) 60.7 (16.4) 69.6 (15.8) 76.7 (11.3) 82.0 (9.7) 65.8 (18.1)

Note: EOWPVT test norm: M = 100; SD = 15. TACL and CELF-WS test norms: M = 10; SD = 3. The bold numbers are means and SDs of the whole sample on each language
measure, as well as the percentage of the whole sample scoring at or above 1 SD of the normative test mean. The percentage can be compared with 85% of the hearing
norming sample who scored at this level. All children were administered the vocabulary and English receptive syntax test. Only sign-only and bimodal children were
administered the ASL receptive syntax test.

Table 4 Means and standard deviations by time, grade, and group on standard scores of reading measures

Test Score Group Kindergarten First grade Second grade Total % ≥ 85

Fall Spring Fall Spring Fall Spring

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

Single-word Standard Spoken 95.6 (16.5) 101.2 97.4 (14.5) 98.1 (13.9) 89.6 (11.0) 89.7 (9.0) 96.1 (14.4) 81%
(WJ Word Id) score (14.1)
Bimodal 96.2 (15.1) 98.3 (14.3) 91.6 (14.3) 90.3 (13.1) 90.3 (15.9) 88.1 (16.3) 92.9 (15.0) 72%
Sign 91.7 (14.4) 91.6 (13.8) 86.0 (14.1) 86.4 (14.4) 80.2 (15.8) 78.6 (16.7) 85.9 (15.6) 53%
Total 94.5 (15.4) 97.1 (14.6) 90.8 (14.9) 90.7 (14.5) 85.5 (15.4) 84.3 (15.7) 91.2 (15.7)
% ≥ 85 76% 81% 66% 69% 49% 53% 67%
Nonword (WJ Standard Spoken 103.7 102.7 97.4 (14.3) 96.6 (13.4) 91.3 (11.7) 91.7 (11.2) 98.7 (14.4) 83%
word attack) score (15.2) (14.0)
Bimodal 97.8 (20.5) 95.0 (17.6) 80.3 (16.1) 81.3 (15.5) 79.6 (20.7) 77.4 (21.1) 85.6 (19.9) 49%
Sign 81.4 (14.1) 73.6 (12.7) 66.1 (12.9) 62.7 (14.8) 62.2 (18.6) 55.6 (21.2) 66.0 (17.6) 13%
Total 96.6 (18.8) 90.4 (19.3) 78.8 (19.0) 78.0 (20.0) 74.7 (21.5) 71.2 (24.3) 82.2 (22.2)
% ≥ 85 67% 60% 34% 36% 36% 37% 46%
Reading comp. Standard Spoken 97.0 (12.8) 96.6 (15.7) 86.4 (15.5) 85.4 (12.0) 81.6 (8.3) 81.1 (8.3) 90.1 (14.5) 65%
(WJ Pass. score Bimodal 96.6 (13.0) 94.0 (16.6) 84.5 (14.2) 80.9 (14.3) 79.0 (15.9) 77.3 (14.7) 86.4 (16.4) 56%
Comp.) Sign 95.1 (12.3) 89.3 (14.2) 79.6 (17.0) 75.9 (14.9) 71.9 (13.0) 68.6 (16.4) 80.4 (17.3) 43%
Total 96.3 (12.6) 93.3 (15.7) 83.0 (15.9) 80.1 (14.4) 76.4 (13.5) 74.4 (15.1) 85.2 (16.7)
% ≥ 85 86% 75% 47% 36% 29% 25% 53%

Note. WJ subtest norms: M = 100; SD = 15. The bold numbers are means and SDs of the whole sample on each reading measure, as well as the percentage of the whole
sample scoring at or above 1 SD of the mean of the normative test mean. The percentage can be compared with 85% of the hearing norming sample who scored at this
level.

scores than first graders (mean = 78.4, g = 0.73) and
second graders (mean = 73.0, g = 1.01). Spoken-only children
(mean = 98.7) had higher standard scores than bimodal (mean
= 85.6, g = 0.75) and sign-only children (mean = 66.0, g = 1.85).
Bimodal children had higher standard scores than sign-only
children, g = 1.10. Scores of sign-only children declined from
68.0 to 64.2 across the school year, g = −0.44. Figure S2 shows
the spoken-only children made steady increases in nonword
reading across time and grade. Bimodal children made smaller
gains. Sign-only children made slower progress and their W
scores declined in second grade.
Reading Comprehension (WJ Passage Comprehension)
The total sample had an average score of 85.2 with 53% of
children scoring within 1 SD. Scores decreased from 86.5 to 83.8
 344 Journal of Deaf Studies and Deaf Education, 2020, Vol. 25, No. 3

Table 5 Means and standard deviations by time, grade, and group on spoken phonological awareness measures

Test Score Group Kindergarten First grade Second grade Total %≥7

Fall Spring Fall Spring Fall Spring

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

Sound Standard Spoken 7.8 (2.1) 8.3 (2.1) 7.4 (2.3) 7.7 (2.9) 6.3 (2.2) 6.7 (0.6) 7.7 (2.3) 74%
match score Bimodal 7.2 (3.3) 7.2 (3.3) 6.3 (2.5) 6.5 (2.2) 6.4 (2.5) 6.3 (2.4) 6.7 (2.8) 54%
(CTOPP) Sign 4.3 (3.7) 6.1 (3.1) 4.5 (2.3) 4.9 (2.1) 5.0 (2.5) 4.8 (2.6) 4.9 (2.9) 29%
Total 6.4 (3.4) 7.2 (3.0) 5.8 (2.6) 6.1 (2.6) 5.7 (2.5) 5.7 (2.4) 6.3 (3.0)
%≥7 67% 66% 32% 34% 38% 40% 50%

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Blending Standard Spoken 4.8 (4.9) 9.4 (3.4) 8.0 (4.0) 9.4 (2.0) 7.0 (3.3) 7.9 (2.7) 7.6 (4.1) 70%
(CTOPP) score Bimodal 4.4 (4.5) 4.8 (5.2) 3.2 (4.0) 3.7 (4.2) 4.3 (4.0) 4.4 (3.6) 4.1 (4.3) 34%
Total 4.6 (4.7) 7.3 (4.9) 5.3 (4.6) 6.1 (4.4) 5.5 (3.9) 6.0 (3.6) 5.8 (4.5)
%≥7 42% 66% 44% 60% 46% 48% 52%

Note. CTOPP subtest norms: M = 10; SD = 3. All children were administered the sound match test. Only spoken language and bimodal children were administered the
blending test. The bold numbers are means and SDs of the whole sample on each spoken phonological awareness measure, as well as the percentage of the whole
sample scoring at or above 1 SD of the mean of the normative test means.

across the school year, g = 0.19. Kindergarteners (mean = 94.8)

had higher scores than first graders (mean = 81.6, g = 0.90)
who scored higher than second graders (mean = 75.4, g = 0.42).
Spoken-only children (mean = 90.1, g = 0.59) and bimodal
children (mean = 86.4, g = 0.39) scored higher than sign-only
children (mean = 80.4), with no difference between the former
two groups. Sign-only children decreased their scores from fall
(mean = 82.4) to spring (mean = 78.3, g = 0.33) as did bimodal
children (fall mean = 87.8; spring mean = 85.0, g = 0.21). In
contrast, spoken-only children’s scores were stable across the
school year (fall mean = 90.4, spring mean = 89.8; g = 0.02).
Figure S2 shows that while all three groups increased their
reading comprehension W scores over time, the gap between
their scores and those of the normative sample increased
with grade.
Reading Results Summary
Sound matching (CTOPP sound matching) The total sample had
an average score of 6.3 with 50% of children scoring within or
above the average range. Sign-only children (mean = 4.9) scored
lower than spoken-only (mean = 7.7, g = 0.88) and bimodal chil-
dren (mean = 6.7, g = 0.60), with no difference between the latter
two groups.
Sound blending (CTOPP blending) Bimodal and spoken-only
DHH children had an average score of 5.8 with 52% of children
scoring within the average range. Scores increased from
fall (mean = 5.1) to spring (mean = 6.6), g = 0.31. Spoken-only
children (mean = 7.6, g = 0.86) had higher scores than bimodal
children (mean = 4.1) and increased their scores from fall
(mean = 6.2) to spring (mean = 9.0), g = 0.53. Figure S3 shows
that both groups increased their blending scores from fall to
spring, but the gap between their scores and those of the hearing
norming group increased with grade.

While most kindergarten DHH children scored within the aver-

age range on all three reading skills tested, standard scores
declined with grade, with large effect sizes. Reading skills of
kindergarteners were similar to the norming sample, with 75%
having spring reading comprehension scores within the average
range. In contrast, only 25% of second graders scored within
the average range in spring. The three groups differed widely
in reading skills. Children in the sign-only group scored lower
than children in the bimodal and spoken-only groups on all three
tests of reading, with medium to large effect sizes. Bimodal and
spoken language children differed on nonword reading, but not
on single-word reading or reading comprehension. By spring of
second grade, children in all three groups had stronger word
reading than reading comprehension skills. By second grade,
although scores declined with grade, spoken-only and bimodal
children still had close to age-appropriate word reading skills,
while sign-only children scored 1 SD below normative means.
All three groups scored below hearing norms in reading com-
prehension.
Spoken PA results summary The majority of spoken-only chil-
dren had spoken phonological awareness skills within the aver-
age range and performed equally well on sound matching and
blending. Bimodal children performed much better on sound
matching than sound blending. Sign-only children scored more
than 1.5 SD below the test norms on sound matching.
Fingerspelling PA
Table 6 displays percentage of items correct for the sign-only and
bimodal children. Tables S11–S13 display model results.
FS imitation Children increased their scores from 34.0 to 45.3%
over the school year, g = 0.58. Kindergarteners had lower scores
(mean = 22.3%) than first graders (mean = 39.0%), g = 0.79, who
had lower scores than second graders, (mean = 61.2%), g = 1.03.
Figure S4 shows the steady increase in percentage correct items
for sign-only and bimodal children with time.

Spoken Phonological Awareness (PA) FS blending Children increased their scores from 17.0 to 26.7%,
Table 5 displays spoken PA standard score means, SDs, and the over the school year, g = 0.50. Kindergarteners (mean = 9.0%)
percentage of the sample scoring within the average range or scored lower than first graders (mean = 20.0%, g = 0.60) who
higher. Tables S8–S10 display model results. scored lower than second graders (mean = 37.4%, g = 0.97).
 S. D. Antia et al. 345

Table 6 Means and standard deviations by time, grade, and group on fingerspelling phonological measures

Test Score Group Kindergarten First grade Second grade Total

Fall Spring Fall Spring Fall Spring

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

F. Percent Bimodal 15.8 (17.6) 28.8 (22.9) 28.9 (22.0) 41.6 (21.0) 54.4 (23.1) 73.4 (16.5) 37.7 (27.3)
Imitation correct Sign 17.1 (16.4) 27.4 (21.2) 36.3 (24.9) 49.7 (25.1) 56.8 (20.8) 62.6 (20.8) 40.9 (26.8)
Total 16.5 (16.9) 28.0 (21.9) 32.9 (23.8) 45.8 (23.4) 55.9 (21.6) 67.0 (19.7) 39.5 (27.0)
F. Percent Bimodal 6.3 (13.0) 14.0 (19.5) 16.8 (18.7) 18.0 (17.9) 27.0 (21.6) 43.2 (21.7) 19.5 (21.4)
Blending correct Sign 3.5 (7.7) 11.9 (19.2) 16.2 (19.5) 28.1 (27.6) 35.5 (24.7) 43.6 (23.2) 22.6 (25.1)

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Total 4.7 (10.5) 12.8 (19.2) 16.5 (19.0) 23.4 (23.9) 32.1 (23.7) 43.4 (22.4) 21.3 (23.6)
F. Elision Percent Bimodal 2.4 (11.4) 7.0 (14.2) 4.3 (8.2) 18.0 (22.9) 25.0 (28.5) 41.7 (35.1) 14.9 (24.7)
correct Sign 4.4 (13.3) 4.9 (11.8) 8.5 (15.6) 20.1 (26.3) 25.4 (27.5) 37.1 (32.9) 16.2 (25.1)
Total 3.5 (12.4) 5.8 (12.9) 6.5 (12.8) 19.1 (24.6) 25.2 (27.7) 39.0 (33.6) 15.6 (24.9)

Note. All means are percentage of correct items. The bold numbers are means and SDs of the whole sample on each fingerspelling phonological measure.

Figure S4 shows the steady increase of percentage correct items
for both groups with time.
FS elision Children increased their scores from 11.3 to
19.9% over the school year, g = 0.56. Kindergarteners did not
increase their scores. First graders increased their scores from
6.5 to 19.1%, g = 0.72. Second graders increased their scores
from 25.2 to 39.0%, g = 0.80. Kindergarteners scored lower
(mean = 4.7%) than second graders (mean = 31.9%), g = 1.49,
but not first graders. First graders (mean = 12.8%) scored lower
than second graders, g = 1.05. As is evident in Figure S4, while
most kindergarteners could not do this task, there was a steady
increase in percentage correct responses from first grade fall
through second grade spring.
FS summary Both sign-only and bimodal children made similar
and steady gains on these three tasks. Imitation was the easiest
task, while elision was the hardest. By second grade, children did
not reach ceiling for any of the fingerspelling tests.
Discussion
The purpose of this research was to describe the language and
literacy of a large sample of young DHH children and exam-
ine their progress longitudinally over the course of a school
year, cross-sectionally from grade to grade, as well as across
groups. We purposefully included DHH students who had dif-
ferent access to language; thus we included children who had
access to spoken or sign language only and also those who
had access to both. The latter group particularly tends to be
little studied. We discuss key findings arranged by the major
constructs: language, reading, and spoken and fingerspelled
phonological awareness.
Language
While children started in kindergarten delayed compared to
the hearing test norms, they made greater than expected gains
during the school year, as shown by increases in standard scores
in all areas of language from fall to spring. Substantially more
children achieved within the average range in vocabulary than in
English syntax. In vocabulary and English syntax, children made
expected progress between kindergarten and second grade, com-
pared to age-based hearing norms. Children who had access
to spoken language made gains in expressive English syntax,
though they scored well below age norms. Those students who
had access to sign made steady gains in ASL syntax.
Our sample achieved an average expressive vocabulary stan-
dard score of 83, lower than the standard score of 91 reported
by Geers et al. (2009), but similar to the average score of 81
achieved by children 8 years of age as reported by Hayes et al.
(2009). Less than 50% of the children scored within the aver-
age range (standard scores 85–115) somewhat worse than the
58% reported by Geers et al. Children in all three grades made
progress during the course of the school year, but kindergartners
and first graders made greater than expected progress (based
on test norms), while second graders made expected progress.
Our sample showed better outcomes than that of Connor et al.
(2000) who reported that, although vocabulary growth was pos-
itive, growth was less than expected based on test norms. In
first and second grades, our total sample showed annual gains
of 3–5 standard score points, which was substantial, but less
than the 8 standard scores in annual gain reported by Hayes
et al. (2009). It is important to note that children did not differ
on vocabulary knowledge based on their group. Despite greater
than expected progress during the school year, the gap between
the DHH students and their typical hearing peers remained wide
across grades. This suggests that elementary-aged DHH children
may be losing the gains they made during the school year over
the summer as has been shown for preschoolers (Scott, Goldberg,
Connor & Lederberg, 2019).
English syntax was the weakest area for all children
as reported also by other researchers (Geers et al., 2003;
Hay-McCutcheon et al., 2008). The children in our sample were
1.5 SD below age norms in receptive English syntax and 2.5 SD
below in expressive English syntax. Access to spoken language
(in this case spoken English) was an advantage in learning
receptive English syntax, reflected in the similar and higher
scores of spoken-only and bimodal children compared to the
sign-only children. However, all three groups showed some
improvement (shown by raw scores) in receptive English syntax
over the school year. While progress might be expected of the
children who had auditory access to English, the sign-only
children without such access also mastered additional items.
We speculate that these children may be developing bilingual
skills and learning to understand English word order from adults
around them who use contact sign.
Consistent with findings by other researchers (e.g., Geers
et al., 2003, 2009), access to spoken language was not sufficient
 346 Journal of Deaf Studies and Deaf Education, 2020, Vol. 25, No. 3
for acquiring age-appropriate expressive English syntax. Only
11% of children in the spoken-only and bimodal groups
scored within the average range on the CELF. However, the
spoken-only children made more than expected progress from
fall to spring, while the bimodal children made expected
progress. The raw scores show that the spoken-only children
mastered about five additional items during the school year;
the bimodal children mastered less than one additional item.
These differences may reflect a different instructional focus
across classrooms; teachers may spend more time in direct or
indirect instruction on English syntax in spoken-language-only
classrooms.
Both groups of children who had access to sign (bimodal and
sign-only) showed substantial improvement in ASL receptive
syntax from fall to spring and from grade to grade. In fact,
by the end of second grade, children were close to ceiling on
this assessment. There was no effect of group, suggesting that
access to spoken language did not appear to inhibit the bimodal
children’s learning of ASL syntactical structures.
Reading
Reading, to a much larger extent than language, was affected by
both grade and group. Kindergarteners showed age-appropriate
skills in all three areas assessed: single-word reading, non-
word reading, and reading comprehension. At kindergarten,
these tests assess children’s emerging literacy skills, namely,
alphabetic knowledge (letter-name, letter-sound) and the ability
to understand concepts depicted by rebuses (not printed
words). Other researchers (e.g., Cupples et al., 2013) have also
reported that hearing loss and language delay does not prevent
acquisition of these early skills. The children in our sample
increased their reading skills from fall to spring and from grade
to grade as indicated by their W scores but made less than
expected progress from kindergarten to second grade, consistent
with findings of other researchers (Harris et al., 2017b; Kyle &
Harris, 2011).
Group had a large effect on reading. Spoken-only children had
age-appropriate nonword and single-word reading skills with
80% of children (across grades) scoring in the average range, very
close to the 85% for the normative sample. Thus, spoken-only
children were able to develop the knowledge of how to sound
out and blend fairly complex words by second grade. Lederberg
et al. (2013) suggest that phonics instruction may be particu-
larly effective with DHH children who have auditory access to
spoken language because letters can serve as visual support for
their learning of spoken phonology. Despite strength in word
reading, spoken-only children showed a decline of 16 standard
points in reading comprehension from kindergarten to second
grade.
Bimodal children had weaker nonword reading skills than
spoken-only children, with 50% scoring within the normative
average range. Despite differences in phonological and spoken
language skills, bimodal and spoken-only children had sim-
ilar word reading and reading comprehension achievement.
These results are in contrast to researchers that report
differences favoring children using spoken language (Dillon &
Pisoni, 2006) but similar to Geers (2003) who found no effect
of communication modality on reading skills for children
with CIs.
Sign-only children were delayed in all three reading skills
and showed greater delays than spoken and bimodal children.
These children’s difficulty with nonword reading would be
expected given their lack of access to spoken language. The fact
that their W scores increased over time suggests they may use
visual and kinesthetic means to acquire knowledge of spoken
phonemes (Haptonstall-Nykaza & Schick, 2007; Kyle, Campbell
& MacSweeney, 2016; Kyle & Harris, 2010). Sign-only children
also showed lower achievement in word reading and reading
comprehension compared to both bimodal and spoken-only
children. Given that the three groups did not differ in overall
language ability (Lederberg et al., 2019), and that bimodal and
sign-only children were exposed to the same sign input in the
classroom, it appears that access to spoken language facilitated
learning to read. Sign-only children need to learn to translate
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English words into ASL which is a complex process (Hoffmeister
& Caldwell-Harris, 2014).
Phonological Awareness
As expected, auditory perception was an advantage for spoken
phonological awareness. Spoken-only children scored within
the low average range on both sound matching and blending.
These results are similar to those reported by James et al. (2008)
for early implanted CI children and what some researchers
have found for DHH kindergarteners (Kyle & Harris, 2011;
Nittrouer et al., 2012). The bimodal children were similar
to the spoken-only children on sound matching but scored
considerably lower in sound blending. Their poorer performance
on blending might have been due to speech production issues.
Although the sign-only children received standard scores about
3 SD below the test norms on sound matching, the raw scores for
this group at each grade level were greater than 0 and increased
from fall to spring. As with nonword reading, these results might
indicate that sign-only children are using visual information
such as speechreading and fingerspelling to identify some
spoken phonemes.
This is the first study to examine developmental change
in fingerspelling PA. Fingerspelling increased across the school
year and grade to grade. Imitation was a relatively easy task
while elision was difficult. The ability to manipulate the sublexi-
cal features of words, as shown in the blending and elision tasks,
increased across time, but even second graders were correct on
less than half of the items. This is worse than the spoken-only
children did on the parallel task of sound blending. It may be
that blending fingerspelling is a more difficult task, but it also
may be a result of lack of instruction on this skill in signing
classrooms. Both the sign-only and bimodal children performed
in a remarkably similar manner on the fingerspelling tasks
achieving similar percentage scores and showing significant
growth from fall to spring and developmental differences across
grades. This may suggest the bimodal children could access the
sublexical features of English words through both auditory and
visual means, and access to one did not seem to inhibit learning
in the other.
Assessment Issues
Every researcher is faced with the issue of how to effectively
and ethically assess DHH children on tests that are not specif-
ically designed or normed for them. We chose to administer
mostly standardized tests of language and reading that were
well validated and widely used with hearing children because
these provided us with interpretable data to examine growth
over a school year and across grades. We purposefully did not
administer every test to each child but assessed children on
the tests that had items that were accessible to them and that
they had the opportunity to acquire based on their language

and communication environment. We judged it unethical to take
time away from classroom instruction for assessments that were
clearly invalid for specific groups of children. Thus, we did not
assess the sign-only children on the spoken phonological aware-
ness blending subtest because it required spoken responses. We
assessed bimodal children on phonological awareness, because
the ESP data indicated that they had auditory access to spoken
English even if they were in a signing educational environment.
We did not assess spoken-only children on ASL receptive syntax
or fingerspelled phonological awareness, because they were not
exposed to and therefore could not acquire sign or fingerspelling.
Modifying standardized tests raises questions about whether
standardized scores and test norms are appropriate to use. On
the other hand, administering standardized tests in one invari-
ant manner to all DHH children raises questions about assess-
ment validity. We believe that making some reasonable modi-
fications to allow the range of DHH children access to the test
items and ensuring that these modifications were consistently
used ensured, as much as possible, that the test scores we
obtained were valid (Sechrest, 2005). In order to ensure that
assessments were valid for each group of children, we made
standard adaptions to each test to accommodate the different
language and communication access and environments, but
we ensured that these adaptations were not idiosyncratic or
dependent on the skill of individual examiners. We ensured that
all examiners were trained to administer each test and took
extreme care with scoring. Despite the variability in children’s
language and communication access, we obtained high inter-
rater reliability for all tests for all groups. Despite these precau-
tions, it is possible that some assessment results, such as spoken
phonological blending, were influenced by children’s expressive
speech capabilities. However, we tested many of these validity
questions for the fall time point (Lederberg et al., 2019) and
found that the tests had good psychometric properties for their
intended constructs and had no strong evidence of bias across
groups.
Implications for further research An important finding of this
study was that the bimodal children in our sample, a group
seldom studied, are learning both English and ASL and making
progress in both languages. However, this finding needs to be
replicated with other samples of bimodal children. We need
to also address how development, and perhaps instruction, in
both languages influences reading development. For example, it
would be informative to study exactly how bimodal children use
spoken and sign language while reading. It would also be infor-
mative to study whether exposure to English-like sign facilitates
reading. Another area that needs further study is the influence
of fingerspelling on reading decoding for DHH children. Our
previous research showed that reading was strongly related to
fingerspelling (Lederberg et al., 2019) and there is some evidence
that signing DHH children benefit from connecting fingerspelled
words to print (Haptonstall-Nykaza & Schick, 2007). However,
evidence is needed on the role of systematic instruction in this
area.
We also need to explore further why children made compar-
atively little progress in reading comprehension. Even spoken-
only children who showed close to age-appropriate language on
word reading and nonword reading showed delays in reading
comprehension by the end of second grade. One explanation
might be that our sample displayed weak English syntax skills;
the SVR suggests that both decoding and language are equally
important to comprehension. Detailed analyses of reading com-
prehension profiles (Kyle & Cain, 2015) hold promise for under-
S. D. Antia et al. 347
standing both the specific language skills and the level of profi-
ciency of these skills necessary to improve outcomes.
Implications for Instruction
The documentation of language and reading status and progress
indicates some areas in which we can focus instructional prac-
tice. In the area of language, although vocabulary is a relative
strength, the majority of children have lexicons that are consid-
erably smaller than their typical hearing peers. English syntax
is a notable weakness even for children with access to spoken
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language. Systematic and intensive instruction in each of these
areas is probably beneficial for all children. On the other hand,
children with access to sign in the classroom appear to be mak-
ing progress in ASL syntax, indicating that, when the structure of
language is visual and therefore completely accessible, current
instructional practices may be sufficient to ensure acquisition.
Classroom instruction and teacher talk can make a difference
in children’s language learning. Duncan and Lederberg (2018)
examined teacher talk in classrooms and reported that explicit
vocabulary instruction and teachers’ reformulation of children’s
utterances were predictors of gains in children’s vocabulary
and expressive English syntax. These authors also reported that
teachers were highly variable in the amount of explicit vocabu-
lary instruction in which they engaged and that explicit morpho-
syntax instruction occurred rarely. Given DHH children’s delays
in vocabulary and English morpho-syntax, it might be necessary
for teachers to engage in explicit direct instruction and for
researchers and practitioners to collaborate on developing and
evaluating instructional practices in these areas.
In the area of reading, all children acquired the simple skills,
such as letter naming and matching rebuses to pictures that are
required at the kindergarten level, but had difficulty with word
reading and comprehension that are required by the second
grade. According to the SVR, reading comprehension requires
both fluent decoding and linguistic comprehension (Gough &
Tunmer, 1986; Tunmer & Chapman, 2012). The challenge, as
always, is identifying the kind of instruction that will help DHH
students make sufficient progress in both these areas. Ongoing
research by the authors documenting reading instruction in
classrooms should assist in identifying the interaction between
instruction and children’s progress in reading. Such knowledge
should help determine effective teaching strategies and the
amount of time children need to be engaged in different types
of reading instruction.
Limitations
A limitation of this study is that we did not include a comparison
group of typically hearing children and thus were only able to
compare the DHH children’s scores to published test norms.
Because our sample is also not matched to the test sample,
a comparison group matched on variables such as socioeco-
nomic status or ethnicity would have provided more precise
information on overlap, progress, and specific areas of delay
in language and reading. Technically, standard scores are also
not on a longitudinally consistent metric. However, the effects
of standardization are likely to be small for the current short-
term longitudinal design. Our sample also does not represent
the larger population of DHH children; rather, we focused on
children in self-contained programs. These children are likely to
be those most in need of intensive instruction, but our results
should not be generalized to all DHH children. Another limita-
tion is that we only received self-reports from teachers about
 348 Journal of Deaf Studies and Deaf Education, 2020, Vol. 25, No. 3
their use of ASL or signed English. We were not able to obtain
observational or other data to confirm the kind of signing occur-
ring in classrooms.
Although we examined differences due to time, grade, and
group on several outcomes, there are many other malleable vari-
ables that influence individual children’s language and reading.
Other researchers, for example, have documented the effects
of age of implantation, age of diagnosis and intervention, and
the quality of early intervention (Dunn et al., 2013; Geers et al.,
2009; Kyle & Harris, 2010; Moeller, 2000). For any single child,
variables impacting language and reading will also include those
related to the home (e.g., parental access to professional support,
home literacy environments) and to school (e.g., quality and
consistency of classroom instruction). Given the low incidence of
childhood deafness, and the difficulty of examining large sam-
ples, it is likely that no single study can examine simultaneously
all possible variables. It is important that readers keep in mind
that the variables examined in this study are only some of the
many variables that will impact children’s language and reading.
Unlike some researchers, we included children whom teach-
ers reported as having mild disabilities. Because it is possible
that the presence of these disabilities may have influenced the
results, we ran post hoc analyses to examine the effects of dis-
ability. Children with mild disabilities scored, on average, lower
than children without disabilities. While there were main effects,
disability status did not interact with time, grade, or group.
Excluding children with mild disabilities changed minimally the
overall means and analyses reported in this paper.
Conclusion
The positive news is that the DHH children in our sample made
progress in vocabulary learning and were acquiring the syntax
of either English (spoken-only and bimodal children) or ASL
(sign-only and bimodal children). Thus, despite delays, children
were acquiring language to which they had access in their
environment. They were also developing phonological process-
ing skills either auditorily or visually. However, for all groups,
delays in reading comprehension increased in higher grades.
Future research might clarify how and why classroom instruc-
tion influences these outcomes. The challenge, as always, will
be to develop evidence-based instructional strategies that will
lead to improvement in literacy for all children while taking
advantage of their opportunities for visual and auditory access
to language.
Supplementary Data
Supplementary material is available at http://jdsde.oxfordjournals.
org/.
Funding
This research was supported by the Institute of Educa-
tion Sciences, U.S. Department of Education through Award
#RC324C120001. The content of this article does not represent
views of the Institute or the U.S. Department of Education.
Conf licts of Interest
No conflicts of interest were reported.
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